Wiki OP Report Question

[lisadams]

Do many of you have the H&P available when you code the surgery, or just the report? For those of you that have the H&P available, if the diagnosis there is more specific do you use that or what the provider stated in the OP report?

Thanks for your input.

 

[codedog]

I always go by the operative report.

 

[mitchellde]

I almost never have the H&P with an op note so I always go by what is in the op note also.

 

[mbort]

I also always go by the op report. The H & P is done prior to surgery therefore may not be as accurate as the op report which "should" reflect the findings in surgery.

Mary, CPC, COSC